District Consumer Disputes Redressal Commission, Faridabad.
Consumer Complaint No.318/2018.
Date of Institution:09.07.2018.
Date of Order: 31.10.2022.
Kailash Chand Goyal Goyal Advocate son of late Shri Mool Chand resident of Kalra Colony, Near Geeta Bhawan Palwal, Tehsil Palwal, Distt. Palwal.
…….Complainant……..
Versus
1. National Insurance Company Limited, Divisional Office No.1, 5-C/1-2B.P. Railway Road, NIT, Faridabad through its Divisional Manager.
2. Park Mediclaim (TPA) Limited 702, Vikrant Tower, Rajinder Place, New Delhi through its Manager, (Pin Code 110008).
.
…Opposite parties
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Sandeep Gupta, counsel for the complainant.
Sh. Neeraj Kumar Gupta, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 30.10.2018.
ORDER:
The facts in brief of the complaint are that the complainant got himself and his wife Smt. Urmila Goyal insured from opposite party No.1 since 2009 continuously without any break under Medi Claim Insurance Policy, which includes individual medical policy vide policy No. 361100/48/15/8500017860 valid from 13.03.2016 to 12.03.2017 for sum insured of Rs.2,00,000/- and the complainant paid insurance premium of Rs.10,274/- from his hard earn money, thereafter the complainant was consumer of opposite party No.1. During the coverage period and enforcement of the said mediclaim insurance policy and on 14.07.2016 the complainant suddenly felt severe chest pain and rushed to QRG Central Hospital (Research Centre, NIT, Faridabad) and was admitted in the said hospital for below mentioned treatment:-
CAD- Acute inferior MI
Single Vessel Disease (CAG done on 14.07.2016)
PTCA + Stent to LCX done on 14.07.2016
LVEF-50-55%
And his Single Vessel Disease (CAG done on 14.07.2016), PTCA + Stent to LCX was done by the doctors of QRG Central Hospital Faridabad on dated 14.7.2016 and the complainant was discharged on 17.7.2016. The QRG Hospital Faridabad for the aforesaid treatment and hospitalization raised a bill of Rs.1,75,196/- out of which Rs.1,00,000/- received from opposite party No.1 and remaining amount of Rs.75,196/- was paid by the complainant to the hospital authorities, because balance amount was not paid by the opposite party without any reason illegally and unlawfully. The opposite parties intentionally and with malafide intention did not re-imburse the total claim of Rs.1,75,196/- and only reimbursed Rs.1,00,000/- and the remaining amount of Rs.75,196/- was paid by the complainant to the hospital authorities and in addition to this amount the complainant paid Rs.10,000/- for purchasing of medicines from the medical stores, which were prescribed by the doctor and consumed within 60 days of discharge from the hospital. Thereafter the complainant sent claim form with all other documents to opposite party No.1 through registered post to send the claim to the complainant but they did not give any reply. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
A . release the amount of mediclaim bills of Rs.75,196/- of QRG Central Hospital Faridabad alongwith interest 18% p.a to the complaint from the due date.
B. pay the medical bills of purchase of medicines of Rs.10,000/- alongwith interest @18% p.a. to the complainant from the date of discharge from hospital which is 17.7.2016 till actual payment.
C. pay Rs. 50,000/- as compensation for causing Mental agony and harassment .
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant had no locus standi to file the present complaint. The policy of complainant of sum insured amount of Rs.2,00,000/- and as per PPN package rates + cost of stent maximum available limit the patient for any one illness (50% of sum insured) had exhausted and terms and conditions 1.2 & 3.1 of the policy only 50% payment was payable for any one illness/insured person and the opposite has rightly reimbursed the amount of Rs.1,00,000/- to the complainant as per norms of policy. Opposite party No.1 denied rest of the allegations leveled in the complaint.
3. Registered notice sent to opposite party No.2 on 27.09.2018 not received back served or unserved. Case called several times since morning. But none had appeared on behalf of opposite party No.2. Therefore, opposite party No.2 was proceeded against ex-parte vide order dated 30.10.2018.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. It is evident from Ex.R2 that the name of the complainant has been mentioned Sanjay Chawla and name of the insured is Mrs. Kamlesh Kumari but the actually the name of the complainant is Kailash Chand Goyal. As per Ex. C28 sum insured amount of the policy of the complainant is Rs.2,00,000/- but in the policy neither any stamp of the company nor deduction of 50% of sum insured amount has been mentioned. But in the terms and conditions of Parviar Mediclaim for Family it has been mentioned in clause No.1.2.E that total expenses incurred for any one illness is limited to 50% of sum insured.
7. After going through the evidence led by the parties, the Commission is of the opinion that no deficiency in service on the part of the opposite parties have been proved. Hence , the complaint is dismissed, Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 31.10.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
